How to undertake a root cause analysis investigation to improve patient safety.

ABSTRACT

RATIONALE AND KEY POINTS Root cause analysis is a tool that can be used when determining how and why a patient safety incident has occurred. Incidents that usually require a root cause analysis include the unexpected death of a patient, serious pressure ulcers, falls that result in injury, and some infections and medication errors. This article outlines the stages of the investigation process for undertaking a root cause analysis. REFLECTIVE ACTIVITY 'How to' articles can help update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.